The European Society of Cardiology released updated guidelines on the management of hypertension, introducing more intensive blood pressure targets and a new "elevated blood pressure" category. The 2024 ESC Guidelines, Co-Chaired by Bill McEvoy, PhD, Professor at the University of Galway, Ireland, and Rhian Touyz, PhD, Professor at McGill University, Canada, represented a significant shift in hypertension management.
The 2024 European Society of Cardiology (ESC) updated guidelines, published in the European Heart Journal, maintained the existing definition of hypertension as blood pressure (BP) ≥ 140/90 mmHg. The new "elevated BP" category aimed to identify more patients at risk for cardiovascular events and facilitate earlier intervention in high-risk groups.
The 2024 guidelines differed from the 2018 ESC/European Society of Hypertension (ESH) Hypertension Guidelines, 2021 ESC Prevention Guidelines, and 2023 ESH Hypertension Guidelines. Previous guidelines generally recommended a two-step approach with an initial treatment target of < 140/90 mmHg, followed by consideration of < 130/80 mmHg. The 2024 guidelines represented a paradigm shift by recommending the lower target (120 to 129 mmHg systolic) as the initial approach for most patients.
Among the key changes were:
- New systolic BP treatment target range of 120 to 129 mmHg for most patients on BP-lowering medication, if well tolerated
- Introduction of an "elevated BP" category defined as 120 to 139/70 to 89 mmHg
- Recommendations for renal denervation in specific cases of resistant hypertension
- Emphasis on out-of-office BP measurements
- Updated dietary advice and lifestyle modifications.
The 2024 guidelines recommended treating most patients to a systolic BP of 120 to 129 mmHg as the initial approach, diverging from previous guidelines that advocated a two-step approach (first treating to < 140/90 mmHg, then considering < 130/80 mmHg). This change was based on recent trial evidence demonstrating improved cardiovascular outcomes with more intensive BP targets across a broad patient spectrum.
Among patients unable to tolerate the primary target, the guidelines introduced the concept of BP "as low as reasonably achievable" (ALARA), particularly in patients who are older or frailer. The focus shifted from chronological age to patient frailty when determining treatment intensity.
The guidelines highlighted that approximately 45% of European adults may have hypertension. They also noted that cardiovascular risks associated with increased BP started at systolic BP levels even below 120 mmHg, underscoring the importance of the new "elevated BP" category.
To support the new intensive treatment targets, the guidelines strongly recommended using out-of-office BP measurements, including ambulatory BP monitors and validated home BP monitors.
The ESC guidelines included recommendations on renal denervation for hypertension treatment. While not recommended as first-line therapy or in patients with severely impaired renal function (estimated glomerular filtration rate < 40 mL/min/1.73 m2) or secondary hypertension, renal denervation could be considered in patients with resistant hypertension uncontrolled on a three-drug regimen, including a thiazide or thiazide-like diuretic. The procedure should be performed at medium-to-high volume centers after shared decision-making and multidisciplinary assessment.
Additionally, the guidelines updated dietary advice on sodium and potassium intake and emphasized the importance of lifestyle modifications across various patient groups and disease stages. The new recommendations included specific guidance on potassium intake as part of the dietary approach to managing hypertension. They also highlighted sex and gender differences in hypertension, integrating this information throughout the document rather than in a separate section.
These changes were "driven by new trial evidence confirming that more intensive BP treatment targets reduce [cardiovascular disease] outcomes across a broad spectrum of eligible patients," Dr. McEvoy emphasized.
The guidelines provided stronger recommendations for using ambulatory BP monitors and validated home BP monitors to accommodate the new, more intensive systolic BP treatment target range. For renal denervation, they emphasized the need for "shared risk-benefit discussion and multidisciplinary assessment." The guidelines stressed that the new target required that treatment be well tolerated, indicating a need for close patient monitoring and potential treatment adjustments.
The 2024 ESC Guidelines included updated recommendations for lifestyle modifications for various patient circumstances and stages of cardiovascular disease and chronic kidney disease. They provided new guidance on sodium and potassium intake. The guidelines integrated sex and gender differences throughout the document rather than as a separate section, reflecting a more comprehensive approach to personalized medicine. They also emphasized patient frailty over chronological age when considering treatment intensity, representing a more nuanced approach to geriatric hypertension management.
